Disclosures. Conclusion/Take Away. Further Disclosure. Start with a case.. Objectives 10/16/2018

Size: px

Start display at page:

Download "Disclosures. Conclusion/Take Away. Further Disclosure. Start with a case.. Objectives 10/16/2018"

Eunice Hawkins
5 years ago
Views:

honoraria by/for Allergan, Bausch & Lomb, Genentech, Luneau Technologies, Maculogix,

effect on the content of this lecture Further Disclosure I have been testing dark

That s what we do Treatment of advanced is not good in the long term We refer for this

1 : Better Outcomes Start with You Dark Adaptation in Dx of Jeffry D. Gerson, O.D., F.A.A.O. Disclosures I am/have been a member of an Ad board or speaker s bureau or been paid honoraria by/for Allergan, Bausch & Lomb, Genentech, Luneau Technologies, Maculogix, Notal, Optos, Optovue, Regeneron, VSP and Zeavision These affiliations will have no effect on the content of this lecture Further Disclosure I have been testing dark adaptation for about 2 ½ years I am BIASED: I WON T Practice without it Standard of care for my patients! Conclusion/Take Away Prevention and early detection are key to ultimate patient success That s what we do Treatment of advanced is not good in the long term We refer for this Objectives Start with a case.. Discuss the landscape and gaps in diagnosis Discuss current management of patients and unnecessary vision loss Establish testing as indicators of risk vs early and subclinical How to integrate more advanced testing into practice management 80 yo (stubborn) male Same appearance OU 20/25- OU What do you want to know? 1

Is it by an ancillary test? Is it a clinical finding? How much do you need to see for it to be? Does it matter? How much do you think you miss? I think I miss about 40% on clinical exam!

2 One more case How do you diagnose? 68yo w T2DM Presenting for routine exam No real complaints, but I don t like driving at night 20/20, no family history What if I told you that they failed their DA screening? Is it by a symptom? Is it by an ancillary test? Is it a clinical finding? How much do you need to see for it to be? Does it matter? How much do you think you miss? I think I miss about 40% on clinical exam!!! I bet you do to! Intermediate may often go undiagnosed Neely et al. evaluated the prevalence of undiagnosed in primary eye care 1288 eyes from 644 patients 75% No per medical record (n=968) 24.8% despite no diagnosis in medical record (n=320) If eyes go undiagnosed, patients may not be prescribed the right treatment plan. The study Reference: concluded Neely DC, et al. JAMA that Ophthalmol. better 2017;135(6): detection strategies may be needed for early. 30% large drusen 10% hyperpigmentation 13.4% hypopigmentation 77.8% small drusen 78.1% intermediate drusen How much is really missed? Recent study shows that 644 patients over 60yo at 31 centers 968 eyes no by OD or MD Images sent to reading center Approx 25% deemed to have 30% of those had large drusen (AREDS(2) classification) 9 Neely et al.prevalence of UnDx in Primary Eye Care. JAMA Ophth 6/17. Dark Adaptation is Severely Impaired by LANDSCAPE Night vision impacted in early disease: 20+ studies patients often give up driving at night Night vision is impaired before day vision Difficult to determine whether night vision is impaired because of or aging 2

Dark Adaptation So What??? Why do we care?

???? (HINT: Why would I ask if it didn t have to do with what I am talking about??) Prevalence of 9.

adults over 75 years old Prevalence of diabetic retinopathy 4.

7 million Americans 2 out of every 100 adults over 40 years old Klein R, et al. Arch Ophthalmology. 2011;129(1):75-80.

Arch Ophthalmology. 2004;122(4):552-563.

3 Dark Adaptation So What??? Why do we care?? Dark adaptation is the process of adjusting from day vision to night vision Easy-to-measure aspect of night vision QUALITY OF LIFE!! THAT IS WHAT WE PRACTICE!! Large Unmet Need What is the most common posterior segment pathology you see in your practice????? (HINT: Why would I ask if it didn t have to do with what I am talking about??) Prevalence of 9.2 million Americans 7 out of every 100 adults over 40 years old 1 out of every 8 adults over 60 years old 1 out of every 3 adults over 75 years old Prevalence of diabetic retinopathy 4.9 million Americans 3 out of every 100 adults over 40 years old Prevalence of glaucoma 2.7 million Americans 2 out of every 100 adults over 40 years old Klein R, et al. Arch Ophthalmology. 2011;129(1): Eye Disease Prevalence Research Group. Arch Ophthalmology. 2004;122(4): Eye Disease Prevalence Research Group. Arch Ophthalmology. 2004;122(4): United States Census There Were (are) Three Stages of Traditional Classification is Based on Retinal Structure Only Early Intermediate Advanced Normal No drusen No pigmentary abnormalities Early Medium drusen > 63 µm and 125 µm No pigmentary abnormalities Choroidal Neovascularization (CNV) 80% Geographic Atrophy (GA) 20% Intermediate 1 large druse > 125 µm and/or Any pigmentary abnormalities Advanced 2 forms Geographic atrophy Neovascular Ferris FL, et al. Ophthalmology. 2013;120(4): The Beckman Committee Classifies Into 4 Stages 18 3

Retinal Function Is Impaired At Least 3 Years Earlier Than Drusen Are Visible ALSTAR Study Impaired dark adaptation identifies

Thus, Impaired Dark Adaptation is a Much Earlier Symptom of than Visual Acuity Normal night vision Subclinical to Early Impaired

At baseline, 24% of the subjects exhibited impaired dark adaptation. status determined at 3-year follow-up visit.

19 20 A More Comprehensive Disease Classification System Structure + Function No Subclinical Early Intermediate No drusen No

Small or medium drusen +/- pigmentary abnormalities Impaired dark adaptation 1 large druse > 125 µm Any pigmentary abnormalities So

Advanced 2 forms Geographic atrophy Choroidal Neovascularization 21 It is Our Responsibility to Communicate Diagnosis with Our

Help them understand why they may have trouble seeing or driving at night. Early diagnosis should be considered good news!

4 Retinal Function Is Impaired At Least 3 Years Earlier Than Drusen Are Visible ALSTAR Study Impaired dark adaptation identifies subclinical at least three years before it can be seen with imaging, OCT or clinical exam. Thus, Impaired Dark Adaptation is a Much Earlier Symptom of than Visual Acuity Normal night vision Subclinical to Early Impaired night vision Prospective Study of Subclinical Sample consisted of 325 adults without clinically detectable. At baseline, 24% of the subjects exhibited impaired dark adaptation. status determined at 3-year follow-up visit. Intermediate Late Owsley, C et al. Ophthalmology. 2016;123(2): A More Comprehensive Disease Classification System Structure + Function No Subclinical Early Intermediate No drusen No pigmentary abnormalities Normal dark adaptation No drusen or small drusen No pigmentary abnormalities Impaired dark adaptation +/- Small or medium drusen +/- pigmentary abnormalities Impaired dark adaptation 1 large druse > 125 µm Any pigmentary abnormalities So there really is a 4 th stage? Pre-Clinical.we will discuss this! Advanced 2 forms Geographic atrophy Choroidal Neovascularization 21 It is Our Responsibility to Communicate Diagnosis with Our Patients Deliver a simple and objective message to your patients. No need to apologize. Help them understand why they may have trouble seeing or driving at night. Early diagnosis should be considered good news! We ll come back to this later 23 We found something early and can do something about it! Normal Gap in Diagnosis of Cervantes-Castañeda RA, et al. Eye (Lond). 2008;22(6): Olsen TW, et al. Ophthalmology. 2004;111(2): Early/Dry Late/Wet Up to 78% of patients have irreversible vision loss at first diagnosis, including 37% who are legally blind in at least one eye Early is not adequately detected by current methods 4

Current Care Leads to Poor Outcomes Call for Early Diagnosis Patient Vision at First Treatment Good 22% Irreversible Impairment BCVA < 20/50 Legally Blind 78% 0% 20% 40% 60% 80%

Ideally these patients would see their primary eye physician and be diagnosed earlier. Cervantes-Castañeda RA, et al. Eye (Lond). 2008;22(6):777-781. Olsen TW, et al. Ophthalmology.

Preventing Unnecessary Vision Loss Available Interventions Prior to Advanced AREDS2 nutritional supplements lower risk of progression by 25% Behavior modification also lowers risk

as 8 weeks VEGF, vascular endothelial growth factor. Age-Related Eye Disease Study Research Group. Arch Ophthalmol. 2001;119(10):1417-1436.

(off label) Risk Factor vs Diagnostic testing Risk Factor: Gives ideas of risk moving forward MPOD, genetics, smoking, Hx Diagnostic testing: Identifies presence of disease OCT,

5 Current Care Leads to Poor Outcomes Call for Early Diagnosis Patient Vision at First Treatment Good 22% Irreversible Impairment BCVA < 20/50 Legally Blind 78% 0% 20% 40% 60% 80% 100% David Brown, MD, FACS Retina Consultants of Houston Many patients are arriving at our practice with unnecessary vision loss. Ideally these patients would see their primary eye physician and be diagnosed earlier. Cervantes-Castañeda RA, et al. Eye (Lond). 2008;22(6): Olsen TW, et al. Ophthalmology. 2004;111(2): Preventing Unnecessary Vision Loss Available Interventions Prior to Advanced AREDS2 nutritional supplements lower risk of progression by 25% Behavior modification also lowers risk of progression Available Interventions for Choroidal Neovascularization (CNV) Prompt anti-vegf therapy can save up to 5 lines of visual acuity Dramatic loss can occur in as little as 8 weeks VEGF, vascular endothelial growth factor. Age-Related Eye Disease Study Research Group. Arch Ophthalmol. 2001;119(10): Age- Related Eye Disease Study 2 Research Group. JAMA. 2013;309(19): Boyer DS, et al. Ophthalmology. 2007;114: Loewenstein A. Retina. 2007;27: (off label) Risk Factor vs Diagnostic testing Risk Factor: Gives ideas of risk moving forward MPOD, genetics, smoking, Hx Diagnostic testing: Identifies presence of disease OCT, clinical exam, DARK ADAPTATION This is an important concept/distinction!! Dark Adaptation Testing Detects Earlier Genetic testing and macular pigment density (MPOD) can indicate a heightened risk for developing, but neither indicates the actual presence of disease. Delayed dark adaptation indicates subclinical at least three years before it is clinically evident. ROLE OF DARK ADAPTATION IN Owsley, C et al. Ophthalmology. 2016;123(2):

AAO Preferred Practice Pattern for Pathogenesis Photoreceptors Cholesterol accumulation leads to panmacular deposits (BlinD and BlamD) American Academy of Ophthalmology.

6 AAO Preferred Practice Pattern for Pathogenesis Photoreceptors Cholesterol accumulation leads to panmacular deposits (BlinD and BlamD) American Academy of Ophthalmology. Preferred Practice Pattern for. (2015) Drusen Sclera Curcio CA, Johnson M. Structure, function, and pathology of Bruch s membrane. In: Ryan SJ, et al, eds. Retina, Vol 1, Part 2: Basic Science and Translation to Therapy. 5th ed. London: Elsevier; 2013: RPE Bruch s Membrane Peaks in these deposits eventually become clinically visible drusen These extracellular cholesterol deposits affect photoreceptor health, causing inflammation and predisposing to CNV In addition, they impair normal transport, including that of vitamin A, across Bruch s membrane Pathogenesis Photoreceptors Drusen RPE Bruch s Membrane In effect, causes a localized deficiency of vitamin A, and dark adaptation is the best test to measure this change DARK ADAPTATION MEASUREMENT Sclera Curcio CA, Johnson M. Structure, function, and pathology of Bruch s membrane. In: Ryan SJ, et al, eds. Retina, Vol 1, Part 2: Basic Science and Translation to Therapy. 5th ed. London: Elsevier; 2013: Dark Adaptometers Goldmann-Weekers Dark Adaptometer Goldmann-Weekers dark adaptometer LKC SST-1 Roland Consult DarkAdaptometer MacuLogix AdaptDx Manual dark adaptometer High patient burden Expert technician required Used in academic clinics for research and retinal degeneration diagnosis 6

LKC Technologies SST-1 Portable Manual Stimulus configuration makes

patients Roland Consult DarkAdaptometer Automated dark adaptometer

al. The Scotopic Sensitivity Tester-1 and the detection of early

Ophthalmic & Physiological Optics: 2006. 26(4), 431 437.

Low patient burden ü Short test duration ü Automated analysis ü

rest stimulus light trial lens holder Simple, noninvasive test

focusing on fixation light, patient is exposed to a mild bleaching

light appears (randomly timed) How AdaptDx Works Dark Adaptation

7 LKC Technologies SST-1 Portable Manual Stimulus configuration makes it unsuitable for detection of dark adaptation impairment in patients Roland Consult DarkAdaptometer Automated dark adaptometer Interfaces with external computer No automated analysis Jackson et al. The Scotopic Sensitivity Tester-1 and the detection of early age-related macular degeneration. Ophthalmic & Physiological Optics: (4), MacuLogix AdaptDx How AdaptDx Works ü No prior adaptation required ü Low patient burden ü Short test duration ü Automated analysis ü Objective output (rod intercept) fixation light forehead rest chin rest stimulus light trial lens holder Simple, noninvasive test performed in-office by ophthalmic technician While continuously focusing on fixation light, patient is exposed to a mild bleaching flash and asked to indicate when a progressively dimmer stimulus light appears (randomly timed) How AdaptDx Works Dark Adaptation stimulus light bleach area fixation light Jackson GR, et al. Vision Res. 1999;39(23): Leibrock CS, et al. Eye (Lond). 1998;12(pt 3b):

Dark Adaptation Is a Major Impairment in AdaptDx Diagnostic Study Rapid Test: 6.

confirmed by retina specialist grading fundus photographs Jackson GR, et al. Invest Ophthalmol Vis Sci. 2014;55(3):1427-1431.

5 minutes High sensitivity: correctly identified 90.6% of confirmed cases High specificity: correctly identified 90.

6% cases exhibit no rod recovery of dark adaptation AdaptDx rapid test ideal for routine clinical use Normal Jackson GR, et al.

Diagnostic Sensitivity Visual field testing to detect glaucoma is 83% sensitive and 95% specific Dark Adaptation Contrast Sensitivity

Acuity Seddon JM, et al. Ophthalmology. 2006;113:260-266. Tikellis G, et al. Clin Experiment Ophthalmol. 2000;28:367-372.

8 Dark Adaptation Is a Major Impairment in AdaptDx Diagnostic Study Rapid Test: 6.5 minutes Extended Test: 20 minutes Normal Multisite study Sample consisted of 127 patients and 21 normal adults Clinical diagnosis confirmed by retina specialist grading fundus photographs Jackson GR, et al. Invest Ophthalmol Vis Sci. 2014;55(3): AdaptDx Diagnostic Study Results Clinically Validated Patients classified as having if dark adaptation >6.5 minutes High sensitivity: correctly identified 90.6% of confirmed cases High specificity: correctly identified 90.5% of confirmed normal cases High overall accuracy of 90.6% cases exhibit no rod recovery of dark adaptation AdaptDx rapid test ideal for routine clinical use Normal Jackson GR, et al. Invest Ophthalmol Vis Sci. 2014;55(3): Jackson GR, et al. Invest Ophthalmol Vis Sci. 2014;55(3): How Good Is 90%? Diagnostic Sensitivity Visual field testing to detect glaucoma is 83% sensitive and 95% specific Dark Adaptation Contrast Sensitivity Photopic Visual Field Retina specialists using slit lamps to detect are 82% sensitive and 91% specific Scotopic Visual Field Visual Acuity Seddon JM, et al. Ophthalmology. 2006;113: Tikellis G, et al. Clin Experiment Ophthalmol. 2000;28: Ervin A-M, et al. Screening for Glaucoma: Comparative Effectiveness. Rockville, MD: Agency for Healthcare Research and Quality; Comparative Effectiveness Review Number Accessed June 6, Owsley et al. (2001) Ophthalmology 108:1196 0% 20% 40% 60% 80% 100% 8

Example of an AdaptDx Report Case 1: Patient name, DOB, and ID number Eye tested and characteristics AdaptDx dark adaptation

intercept time and clinician assessment (>6.

20/20 OU No family Hx Nonsmoker Subtle drusen Unremarkable OCT Abnormal dark adaptation WHAT DOES A POSITIVE TEST MEAN?

Report Mean? You find a patient who has impaired dark adaptation.

9 Example of an AdaptDx Report Case 1: Patient name, DOB, and ID number Eye tested and characteristics AdaptDx dark adaptation curves 75 Year old female 20/25 OU No family Hx Nonsmoker Large soft drusen OCT findings of drusen Abnormal dark adaptation Rod intercept time and clinician assessment (>6.5 minutes consistent with ) Courtesy of Amanda Legge, OD, Wyomissing Optometric Center Case 2: Subclinical 65 Year old female 20/20 OU No family Hx Nonsmoker Subtle drusen Unremarkable OCT Abnormal dark adaptation WHAT DOES A POSITIVE TEST MEAN? Courtesy of Amanda Legge, OD, Wyomissing Optometric Center Case Example With Positive Test Report What Does a Positive Test Report Mean? You find a patient who has impaired dark adaptation. Look at the patient s other characteristics with imaging tools 1. Are there drusen? 2. Are there pigmentary changes including geographic atrophy? 3. Is there evidence of choroidal neovascularization? NOW WHAT? Other characteristics of No other characteristics of Patient Subclinical Patient 9

Co-Manage as Appropriate The AdaptDx helps Detect and Monitor Patients as Their Disease Progresses Sample Dark Adaption Progression Over Time (Rod Intercept in minutes) Optometrist or General

10 Co-Manage as Appropriate The AdaptDx helps Detect and Monitor Patients as Their Disease Progresses Sample Dark Adaption Progression Over Time (Rod Intercept in minutes) Optometrist or General Ophthalmologist Retina Specialist Advanced Intermediate Early Subclinical Baseline Stable Worsening High Risk Monitor & TreatEvery 6 months, then 3 months No Screen Year 1 Year 2 Year 3 Year 4 Undetected is a Significant Problem How Diagnosis Changes Your Practice Good for your patients If is detected early, there are effective interventions that can preserve vision and improve quality of life Sample of 100 consecutive older adults (over age 60) with normal retinal health based on clinical exam were tested using AdaptDx. 39% (39 of 100) had previously undetected Good for your practice An patient is estimated to add from $350 to $600 per year to practice revenue Based upon prevalence, revenue should be 3X glaucoma revenue Jeffry Gerson, OD, Grin Eye Care Rumpakis, J. Optometric Management. Jul.1, Rumpakis, J. The Center of Excellence. AOA Annual Meeting It is Our Responsibility to Communicate Diagnosis with Our Patients Deliver a simple and objective message to your patients. No need to apologize. Help them understand why they may have trouble seeing or driving at night. Early diagnosis should be considered good news! We found something early and can do something about it! Key Takeaways is a highly prevalent condition that causes preventable vision loss Proactive detection and management of early and subclinical can transform a practice and ensure better patient outcomes Dark adaptation testing can help preserve vision and improve quality of life 59 10

Thank You! Jeffry D. Gerson, O.D., F.A.A.O. jgerson@hotmail.

92284 ($62 avg) üfda 510K cleared (K100954) üce marked The Impact of Detection & Management Good for your patients Early detection & active monitoring of can preserve vision and maintain quality of

11 Thank You! Jeffry D. Gerson, O.D., F.A.A.O. UPDATED/ ALTERNATIVE SLIDES AdaptDx Advantages üno prior adaptation or pupil dilation required ülow patient burden üeasy to administer üautomated analysis üobjective output (Rod Intercept) ücpt ($62 avg) üfda 510K cleared (K100954) üce marked The Impact of Detection & Management Good for your patients Early detection & active monitoring of can preserve vision and maintain quality of life Good for your practice An patient is estimated to add from $350 to $600 per year to practice revenue Rumpakis, J. Optometric Management. Jul.1, Rumpakis, J. The Center of Excellence. AOA Annual Meeting Better Disease Management Earlier Detection and Proactive Disease Management Can Save Vision Examination Annual, semi-annual, or more frequent exams Testing BCVA, biomicroscopy, dark adaptation, imaging Management Lifestyle modification, nutraceuticals, blue blocking/uv protection, Amsler grid Referral Immediate consultation with retina specialist upon clinical signs or symptoms of CNV American Optometric Association. Care of the patient with age-related macular degeneration. (2004) American Academy of Ophthalmology. Preferred Practice Pattern for. (2015) Old Standard of Care: ECPs Are Not Finding Wet Before There Is Irreversible Vision Loss: 100% 80% 60% 40% 20% 0% Patient s Vision at First Treatment With Anti-VEGF (no AdaptDx) 78% Legally Blind BCVA Worse Than 20:50 Irreversible Impairment Outcomes 22% Good Klein R, et al. Arch Ophthalmology. 2011;129(1): Eye Disease Prevalence Research Group. Arch Ophthalmology. 2004;122(4): Eye Disease Prevalence Research Group. Arch Ophthalmology. 2004;122(4): United States Census 100% 80% 60% 40% 20% 0% New Standard of Care: The AdaptDx Has 90% Sensitivity & Specificity: Probability of Finding (with AdaptDx) 10% Poor Outcome Outcomes 90% Good Outcome 11

Additional Patient Care Triggered by Diagnosis ü Reimbursable dark adaptation testing ($63 Average) ü Increased exams ü OCT scans ü Fundus photographs ü Eye health supplements ü Blue blocking lenses

impairment Tests night vision complaints to differentiate cataract from Clinical Utilization Case #2 Two optometrists, comprehensive practice Patient-pay initial testing at future dedicated visit

12 Additional Patient Care Triggered by Diagnosis ü Reimbursable dark adaptation testing ($63 Average) ü Increased exams ü OCT scans ü Fundus photographs ü Eye health supplements ü Blue blocking lenses ü UV protective sunglasses PRACTICE INTEGRATION MODELS Clinical Utilization Case #1 Multispecialty optometry practice Insurance reimbursement only Primarily tests known patients to benchmark impairment Tests night vision complaints to differentiate cataract from Clinical Utilization Case #2 Two optometrists, comprehensive practice Patient-pay initial testing at future dedicated visit with follow-on insurance visits Self-pay dark adaptation test offered to patients meeting risk profile (over 60, family history of, smoker, overweight, poor night vision, etc) Cataract vs benchmark testing 10% decline testing 90% elect to pay for testing Rapid Test to discriminate night vision impairment due to cataract vs retinal pathology Dedicated testing visit Patients can be asked again at next visit 1 hour follow-on appointment scheduled Extended Test on both eyes to benchmark dark adaptation time that can be tracked from visit to visit Determine patient management program based on results of testing (eg, quarterly, semi-annual, or annual appointment schedule) Previously undiagnosed is discovered in 25% of these patients Clinical Utilization Cast #3 Proactive Testing Model High-volume refractive surgery/cataract practice; multiple ODs/MDs Patient-pay initial testing during current visit with follow-on insurance visits Self-pay dark adaptation test offered to patients meeting risk profile (over 50, family history of, smoker, overweight, poor night vision, etc) Patients can be asked again at next visit 40% decline testing 60% elect to pay for testing Testing performed at current visit using Rapid Test of one eye to get yes/no determination 40% of patients are impaired (test positive) 60% of patients are unimpaired Initial Assessment Testing with AdaptDx Rapid Test based on risk factors Discovery of previously undetected early and subclinical Benchmark characterization: - AdaptDx Extended Test - imaging Patient self-pay or ICD night blindness, unspecified Early : ICD dry or Subclinical ADM: ICD abnormal dark adaption Subsequent Management Increased exam frequency (as appropriate) with follow-up testing: - AdaptDx Extended Test - imaging Recommend or sell nutraceuticals (as appropriate) Early : ICD dry or Subclinical ADM: ICD abnormal dark adaption 12

13 Problem Is Growing as the Population Ages Dark Adaptation Is NOT a Risk Factor for > 75 years > 60 years > 40 years Prevalence by Age in US 1 in 3 1 in 8 1 in 14 Genetic testing and macular pigment density (MPOD) can indicate a heightened risk for developing, but neither indicates the actual presence of disease. Impaired dark adaptation is NOT a risk factor. It is the earliest manifestation of disease. Klein R, et al. Arch Ophthalmology. 2011;129(1): Patient Treatment Protocol Subclinical Patient Treatment Protocol Examination: annual, semi-annual, or more frequent dilated exams (depending on severity) (Consider genetic testing) Testing: BCVA, biomicroscopy, macular function assessment (such as dark adaptation), imaging (photos or OCT), MPOD Management: consider anti-oxidant supplementation & light protection, provide lifestyle counseling, AG vs electronic Referral: immediate consultation with retina specialist upon clinical signs or symptoms of choroidal neovascularization Examination: monitor as appropriate depending on risk factors (age, family history, smoking, weight, genetics) Testing: BCVA, biomicroscopy, macular function assessment (such as dark adaptation), MPOD, imaging (fundus photos, OCT) Management: consider nutraceutical supplementation & light protection, provide lifestyle counseling American Optometric Association. Care of the patient with age-related macular degeneration. (2004) 13

25% of normal 2/20/2018. Practical Guidelines for the Treatment of AMD 78% 22% Overview. AMD Information Overload

25% of normal 2/20/2018. Practical Guidelines for the Treatment of AMD 78% 22% Overview. AMD Information Overload I am a consultant / or have financial interest in: Practical Guidelines for the Treatment of Maculogix J&J Acuvue Vision Source Ocusoft Pogo Tech Jeffrey W. Jones, OD Longview, TX 75605 jjoneseye@gmail.com